Medicare approves payment for 6 spine surgery procedures in the ASC setting as of 1/1/2020

OUTPATIENT SPINE SURGERY

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EFFECTIVE JANUARY 1, 2020, MEDICARE WILL BEGIN PAYING FOR THESE PROCEDURES OUTSIDE THE INPATIENT HOSPITAL SETTING

About the Author

About the Author

Maria Todd is frequently hired as a consulting expert and trusted authority on pricing strategies for bundled price surgeries. She helps medical groups, individual physicians, hospitals and ambulatory surgery facilities and other healthcare providers to pivot to new pricing and operational strategies when reimbursement rules by Medicare and commercial insurance plans change or are updated.

Maria believes that many spine surgeries can be safely performed in the outpatient setting at a far lower cost that inpatient surgery and hospital stays that cost more with no additional value proposition. Learn why she argues that employers and consumers should investigate having surgery in the ASC and save up to 80% from inpatient hospital prices.

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Table of Contents

What’s this about?

  • Over 145 ambulatory surgery centers (ASCs) across the USA offer minimally invasive spine surgery. 
  • About 90% of patients who underwent their surgery for spine problems in an ASC needed less medication for pain and consumed less morphine, fentanyl and oxycodone. 
  • The Veterans Administration reported that all of the minimally invasive spine surgery patients treated in an ASC returned to duty three months postoperatively. The patients experienced a significant reduction in self-reported pain and disability 12 months postoperatively. 
  • Case costs for these surgeries tend to run close to the $100,000 price point in the hospital setting when all bills are gathered, and in the ASC, cash pay pricing can be as much as 80% less for the same surgery, same procedure, same equipment and even same surgeon performing the procedure.
  • Research published in Neurosurgery found outpatient spine procedures are just as safe as — or safer than — procedures performed in an inpatient setting.

Patients whose stubborn low back pain and leg pain has been managed conservatively for three months with:

  • rest
  • exercise
  • avoidance of activities that aggravate pain
  • application of heat/cold modalities
  • local injections
  • lumbar bracing
  • chiropractic manipulation
  • Supervised physical therapy (PT) (activities of daily living [ADLs] diminished despite completing a plan of care)
  • Anti-inflammatory medications, oral or injection therapy as appropriate, and analgesics

depending on the diagnosis, lumbar spinal fusion (arthrodesis) may be considered for certain conditions.

How have the rules changed?

CMS removed six spinal procedures from the inpatient-only list as of 1/1/2020 Medicare Hospital Outpatient Prospective Payment System and have approved the procedures for payment when performed in the Ambulatory Surgical Center setting. Previously, the procedures could be done with expected safety for patients who had insurance other than Medicare Payment System. 

Which spinal procedures can now be paid by Medicare when performed in the ASC setting? 

The six spinal procedures removed from the inpatient only list include:

1. Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; lumbar. CPT code: 22633

2. Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; lumbar; each additional interspace and segment. CPT code: 22634

There are many surgical techniques to achieve lumbar spinal fusion and they include different surgical approaches (anterior, posterior, lateral) to the spine, different areas of fusion (intervertebral body,interbody), transverse process (posterolateral), different fusion materials (bone graft and/or metal instrumentation), and a variety of ancillary techniques to augment fusion.

3. Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical. CPT code: 63265

In a related study, published in Spine investigated the adverse event profile of cervical total disc replacements (CTDRs) performed in the outpatient versus inpatient setting. Study authors found no difference in perioperative complications between the inpatient and outpatient CTDRs. A laminectomy is not the same as a cervical total disc replacement, but the evidence is pointing to an increasing number of neck and back surgery procedures being performed safely in the outpatient setting. In the 1980s, one would likely spend a full week in the hospital for a spine procedure.

4. Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic. CPT code: 63266

5. Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar. CPT code: 63267

6. Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral. CPT code: 63268

Background:

This new policy does not address when surgery is indicated due to:

  • Acute spinal fracture or neural compression after spinal fracture
  • Epidural compression or vertebral destruction from tumor or abscess
  • Spinal tuberculosis
  • Spinal debridement for infection (e.g., osteomyelitis)
  • Spinal deformity from idiopathic scoliosis over 40 degrees.
  • Progressive degenerative scoliosis

Indications

Spinal stenosis for a single level (for example, L4-L5) with associated spondylolisthesis and symptoms of spinal claudication and radicular pain. These patients with associated spondylolisthesis can also have motor deficit and / or described (non-iatrogenic or iatrogenic) instability on pre-operative flexion and extension radiographs. 

The pain must represent a significant functional impairment despite a history of 3 months of conservative therapy (non-surgical medical management) as clinically appropriate as listed previously.

Spondylolisthesis manifested by back pain with or without spinal claudication (cramping leg pain), radicular pain (pain that shoots down the leg), motor deficit (when the muscles don’t function properly because of the spinal nerve problem) when ANY of the following criteria are met:

  • Confirmed progressive deformity usually Grade II or higher (slippage at 26% or greater)
  • Multilevel spondylolysis
  • Symptomatic low-grade spondylolisthesis associated with back pain and significant functional impairment despite a history of 3 months of conservative therapy (non-surgical medical management) as clinically appropriate.
  • Spondylolysis demonstrated on imaging studies (e.g., CT scan, MRI, bone scan, or discography) as the likely cause of pain.

What about if you already had previous back surgery?

You may be able to have repeat lumbar fusion paid by Medicare following prior fusion for associated spondylolisthesis (for example anterolisthesis) with all the following:

  • Recurrent symptoms consistent with neurological compromise
  • Significant functional impairment
  • Nerve compression is documented by recent post-operative MRI CT or x-rays
  • Unsuccessful improvement despite 3 months of clinically appropriate post-operative nonsurgical medical management
  • When the patient has had some relief of pain symptoms following the prior spinal surgery.

What if you had a failed back surgery in the past? 

Medicare may pay for treatment of pseudoarthrosis (i.e., nonunion of prior fusion) at the same level after 12 months from prior surgery and all of the following are met:

  • Imaging studies confirm evidence of pseudoarthrosis (e.g., radiographs, CT)
  • Unsuccessful improvement despite 3 months of clinically appropriate post-operative nonsurgical medical management
  • Patient had some relief of pain symptoms following the prior spinal surgery.

When Medicare may decide not to pay for your surgery

Initial lumbar spinal fusion for degenerative disease of the lumbar spine is not considered medically necessary and is noncovered:

  • When performed with initial primary laminectomy/discectomy for nerve root decompression or spinal stenosis, without documented spondylolisthesis and/or spondylolysis.

Which screening and diagnostic studies are required prior to surgery?

***Spondylolishthesis and/or spondylolysis must be confirmed with appropriate pre-operative diagnostic imaging (e.g., plain film, CT, MRI, discography, bone scan, and/or gallium scan).

Percutaneous sacrioiliac minimally invasive joint stabilization for arthodesis (CPT code: 27279) can be indicated for the treatment of sacro-iliac joint (SIJ) pain for patients with low back/buttock pain who meet all of the following criteria:

* Diagnostic imaging studies that include all of the following:

  • plain radiographs and a CT or MRI of the SI joint that excludes the presence of destructive lesions (e.g. tumor, infection) or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion
  • ipsilateral hip plain radiographs to rule out osteoarthritis
  • lumbar spine CT or MRI to rule out neural compression or other degenerative condition that can be causing low back or buttock pain
  • * and, at least 80 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced SIJ injection on two separate occasions

In 2017, Medicare decided to open an investigation into this procedure (27279) to determine if it was undervalued and if an increase in payment was appropriate. The decision would set precedent for not only Medicare and Medicaid, but also for many insurers who base payments off a reference standard of pricing relative to what Medicare pays.

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Maria is a bestselling author and a top healthcare industry influencer and thought leader. She has excellent references and a huge project portfolio spanning 40+ years in healthcare business development and management.

She holds 25 copyrights, several trademark registrations, and shares several patent applications for software inventions.

She’s been recognized with numerous industry lifetime achievement awards for her work in contracted reimbursement, managed care, physician integration and alignment, and health tourism in the USA and 116 countries.

She is the Chief Transformation Officer of SurgeryShopper.com 

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